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Pharmacy (Part D) appeals

Your benefits as a member of Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) (SCFHP Cal MediConnect) include coverage for many prescription drugs. Most of these drugs are “Part D drugs.” There are a few drugs that Medicare Part D does not cover but that Medi-Cal may cover. This section only applies to Part D drug appeals.

The SCFHP Cal MediConnect List of Covered Drugs, or also known as the Drug List, includes some drugs with an asterisk (*). These drugs are not Part D drugs. For appeals or coverage decisions about drugs with an asterisk (*) symbol, follow the process in Medical Care Appeals.

If you need help, please call SCFHP Cal MediConnect Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. We can also help you in your preferred language. You can also get help or information from the Cal MediConnect Ombuds Program by calling 1-855-501-3077 (TTY: 1-855-847-7914), Monday through Friday, 9 a.m. to 5 p.m. The call is free. Or visit their website at www.healthconsumer.org.

If you disagree with a coverage decision we have made, you can appeal our decision.

  • Do you need a drug that isn’t on our Drug List or need us to waive a rule or restriction on a drug we cover?
    • You can ask us to make an exception. This is a type of coverage decision.
  • Do you want us to cover a drug on our Drug List and you believe you meet any plan rules or restrictions (such as getting approval in advance) for the drug you need?
    • You can ask us for a coverage decision.
  • Do you want to ask us to pay you back for a drug you already got and paid for?
    • You can ask us to pay you back. This is a type of coverage decision.
  • Have we already told you that we will not cover or pay for a drug in the way that you want it to be covered or paid for?
    • You can make an appeal. This means you are asking us to reconsider.

For more information on how to ask for a coverage decision, read Chapter 9, Section F4 of the SCFHP Cal MediConnect Member Handbook or see Prescriptions & Part D Coverage Decisions & Exceptions. For more information on how to request an appeal, continue reading below or read Chapter 9, Section F5 and F6 of the SCFHP Cal MediConnect Member Handbook. Find a copy of the SCFHP Cal MediConnect Member Handbook in Member Materials.

Level 1 Appeal for Part D drugs

If you disagree with a coverage decision we have made, you can appeal our decision. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. This section tells you how to request a Level 1 appeal for Part D drugs.

To start your appeal, you, your doctor or other prescriber, or your representative must contact us.

  • If you are asking for a standard appeal, you can make your appeal by sending a request in writing. You may also call or fax us to make your request. You, your representative, or your doctor (or other prescriber) can do this.
    • You can call us at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
    • You can fax us at 1-408-874-1962.
    • You can complete and print the Request for Redetermination of Part D Drug Denial form found in Member Materials and mail it to us at:

      Attn: Grievances and Appeals Department
      Santa Clara Family Health Plan
      PO Box 18880
      ​San Jose, CA 95158
    • You can also use our online Grievance and Appeal Form.
  • If you want a fast appeal, you may make your appeal in writing or you may call us.
  • Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. For example, good reasons for missing the deadline would be if you have a serious illness that kept you from contacting us or if we gave you incorrect or incomplete information about the deadline for requesting an appeal.
  • You have the right to ask us for a copy of the case file. To ask for a copy, call SCFHP Cal MediConnect Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

If you wish, you and your doctor or other prescriber may give us additional information to support your appeal.

If your health requires it, ask for a "fast appeal"

If you are appealing a decision our plan made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a “fast appeal."

Our plan will review your appeal and give you our decision. We take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said No to your request. We may contact you or your doctor or other prescriber to get more information. The reviewer will be someone who did not make the original coverage decision.

Deadlines for a "fast appeal"

If we are using the fast deadlines, we will give you our answer within 72 hours after we get your appeal, or sooner if your health requires it.

If we do not give you an answer within 72 hours, we will send your request to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review your appeal.

  • If our answer is Yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal.
  • If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No.

Deadlines for a "standard appeal"

If we are using the standard deadlines, we must give you our answer within 7 calendar days after we get your appeal, or sooner if your health requires it, except if you are asking us to pay you back for a drug you already bought. If you are asking us to pay you back for a drug you already bought, we must give you our answer within 14 calendar days after we get your appeal. If you think your health requires it, you should ask for a “fast appeal.”

If we do not give you a decision within 7 calendar days, or 14 calendar days if you asked us to pay you back for a drug you already bought, we will send your request to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review your appeal.

If our answer is Yes to part or all of what you asked for:

  • If we approve a request for coverage, we must give you the coverage as quickly as your health requires, but no later than 7 calendar days after we get your appeal or 14 calendar days if you asked us to pay you back for a drug you already bought.
  • If we approve a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get your appeal request.

If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No and tells how to appeal our decision.

Level 2 Appeal for Part D drugs

If we say No to part or all of your Level 1 appeal, you can choose whether to accept this decision or make another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision.

  • If you want the IRE to review your case, your appeal request must be in writing. The letter we send about our decision in the Level 1 Appeal will explain how to request the Level 2 Appeal.
  • When you make an appeal to the IRE, we will send them your case file. You have the right to ask us for a copy of your case file by calling SCFHP Cal MediConnect Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.
  • You have a right to give the IRE other information to support your appeal.
  • The IRE is an independent organization that is hired by Medicare. It is not connected with this plan and it is not a government agency.
  • Reviewers at the IRE will take a careful look at all of the information related to your appeal. The organization will send you a letter explaining its decision.

Deadlines for “fast appeal” at Level 2

If your health requires it, ask the Independent Review Entity (IRE) for a “fast appeal.”

  • If the IRE agrees to give you a “fast appeal,” it must give you an answer to your Level 2 Appeal within 72 hours after getting your appeal request.
  • If the IRE says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 24 hours after we get the decision.

Deadlines for “standard appeal” at Level 2

If you have a standard appeal at Level 2, the Independent Review Entity (IRE) must give you an answer to your Level 2 Appeal within 7 calendar days after it gets your appeal. If the appeal is about payment, the IRE will give you an answer within 14 calendar days after it gets your appeal.

  • If the IRE says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 72 hours after we get the decision.
  • If the IRE approves a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get the decision.

What if the Independent Review Entity says No to your Level 2 Appeal?

No, means the Independent Review Entity (IRE) agrees with our decision not to approve your request. This is called “upholding the decision.” It is also called “turning down your appeal.”

If you want to go to Level 3 of the appeals process, the drugs you are requesting must meet a minimum dollar value. If the dollar value is less than the minimum, you cannot appeal any further. If the dollar value is high enough, you can ask for a Level 3 appeal. The letter you get from the IRE will tell you the dollar value needed to continue with the appeal process.

How can I find out the status of my appeal?

You can call us at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

How to get the aggregate number of all grievances, appeals, and exceptions filed with SCFHP Cal MediConnect

You can get the aggregate number of all grievances, appeals, and exceptions filed with SCFHP Cal MediConnect by contacting the SCFHP Grievance and Appeals Department:

Call:
Toll free: 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

Fax: 1-408-874-1962

Write:

Attn: Grievance and Appeals Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

File a complaint about SCFHP Cal MediConnect directly with Medicare

To file a complaint about SCFHP Cal MediConnect to Medicare, click here to use the form on Medicare’s website. Or you can call Medicare 24/7 at 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048) to ask for help.

Accessibility

You can ask for published materials for free in other formats, such as large print, Braille, or audio. Call SCFHP Cal MediConnect Customer Service for help.

If you speak a language other than English, language assistance services, free of charge, are available to you. Call SCFHP Cal MediConnect Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. The call is free.

Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.

Enrollment in Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) (SCFHP Cal MediConnect) depends on contract renewal.

Last updated 12/31/2020

H7890_16035W Accepted